text, Joslin writes, “I can never repay Dr. Allen’s many and continued kindnesses or sufficiently acknowledge the inspiration which his fruitful and persistent work awakens” [16].
As a consequence of having a large practice in diabetes but few effective tools, Joslin had by 1916 lost 62 patients under the age of 15 years, with coma always the cause of death [21]. In adopting Allen’s treatment, first removing fat, then protein, then carbohydrate from the diet, Joslin forestalled hyperglycemic crises and ketoacidosis that are known today to induce diabetic coma [22]. Quickly noticing the improvement, especially among his child patients, Joslin reported “the gratifying fact” that in the past year, “48 cases (probably mostly adults) have been treated by me in hospitals without a death” [21]. Two years later he would comment, “Whereas formerly the prognosis for children less than ten years of age was measured in months, today it is rare for a child to live for less than one year.” Furthermore, Joslin saw a pragmatic benefit for general practitioners: “The greatest advantage of the fasting treatment introduced by Dr. Allen lies in its simplicity and in the removal of the need for quantitative urinary examinations” [16].
His clinical experience deeply impressed Joslin: “For myself, I consider the impression which I have thus obtained of far more value than any statistics which my records afford, but it is almost my duty to present these as well.” He summarized his cases in tables, but was not an adept statistician. Even his arithmetic is incorrect! (See Mazur [1] for my reanalysis of his case data.) Based on his own cases, starvation did not seriously prolong life, but it did largely eliminate coma as the proximate cause of death. Joslin was jubilant about this, concluding, “I am coming to feel that coma no longer represents the culmination of the disease, but that it is an avoidable accident” [16].
In all his subsequent publications, Joslin praises Allen as the primary innovator in diabetic therapy. The second edition of his textbook, Treatment, opens with Joslin writing, “The advance in the treatment of diabetes, which began with the introduction of fasting by Dr. F. Allen, continues, and statistics are now available to show it. So-called acutely fatal diabetes is disappearing and the first year of diabetes is no longer, as was only too recently the case, the diabetic’s danger zone. Already I have quite a series of patients who have outlived their normal expectation of life at the age of onset of their diabetes.” And later in the text:
Looking back upon the treatment of diabetes before Allen’s introduction of prolonged fasting, it really seems... that our patients were nursed rather than treated. Only those who have cared for many patients by the older methods can appreciate the advance which Allen has given to diabetic therapy. [16]
In February 1916, The New York Times reported a symposium held at the New York Academy of Medicine on the “Allen Plan.” Whether or not Joslin had a hand in setting up this event, he gave it his imprimatur. Dissenters also participated, but the story’s headline, “Radical New Method of Treating Diabetes,” suggests that it was a platform for Allen, who told his colleagues, “Many of our patients run up the eight flights of our stairs at the hospital of the institute twenty times a day. Then they walk eight or ten miles in the open air. They also skip the rope and toss medicine balls. We are making athletes of them, thin as they are, and surely it can at least be said of them they are not neurasthenic” [23]. Poignantly, Joslin later adds “a discouraging nature (of the new treatment), for a new cause of death appears in my records – namely inanition, and to this 3 cases succumbed. Inanition, like coma, may be rightly considered at present as evidence of unsuccessful treatment” [16]. Joslin blamed himself for these deaths.
Allen Back in Civilian Life
By the war’s end, Allen was a star in the diabetes community, championed by Joslin, with imitators and critics. In 1919 Allen’s second book appeared as a Rockefeller Institute publication with his former associates at the hospital, Dr. Stillman and Dr. Fitz, as coauthors, though Allen says in his memoir that he wrote the entire text.
Again a civilian, Allen purchased an abandoned estate with a golf course in suburban Morristown, New Jersey, converting it into a hospital and laboratory. His Physiatric Institute opened in 1920, its Greek-derived name indicating treatment through natural means. Rates varied with the quality of accommodation, whether wards or luxurious rooms. Diet therapy was individualized, requiring almost as many dieticians as nurses. Patients who were able could recreate in the grounds or the nearby town. Allen held complete control of the Institute, its medical, administrative, and fundraising aspects, and, to the extent he could, its patients.
The Institute grew rapidly, holding 1- or 2-month-long teaching courses per year, drawing physicians from across the nation and disseminating calorie-restriction therapy. Soon young Elizabeth Hughes was brought for treatment, and her famous father became a supporter. After 1922, both Allen and Joslin were among the early adopters of insulin, but whereas Joslin’s patient-care model flourished, Allen’s operation contracted, especially after the crash of 1929. He was evicted from the Institute’s property for defaulting on the mortgage [7].
Conclusions
For a brief period, from 1915 until the discovery of insulin in 1922, prolonged fasting and permanent calorie restriction were championed in North America by Frederick Allen and Elliott Joslin. Offering hope for child diabetics and their parents, and for severely afflicted adults, the Allen Plan was quickly and widely adopted. This episode shows us the frail basis upon which new and extreme treatments could become common practice.
Allen developed his therapeutic ideas in 1913 at Rockefeller Hospital, saying they were based on his experiments with partially pancreatectomized dogs. He doubtlessly did abundant work on animals at Harvard prior to 1913, but these results, published in detail, have no bearing on calorie restriction therapy. Later animal experiments at Rockefeller do relate to the treatment but are published (in an era before peer review) only sketchily and are impossible to critically evaluate. Not even the number of comparison animals is reported, which may have been as few as two. If Allen did establish a reliable model for calorie-restriction therapy in dogs, he did not at the time support it with detailed results in the public record.
From 1914 to 1917 Allen and coworkers treated about 100 patients in the diabetic ward of Rockefeller Hospital. Allen claimed success in eliminating or avoiding glycosuria and acidosis, mitigating the worst outcomes of diabetes, and reinvigorating his patients – if they adhered strictly to their diets. In his 1919 book, Allen described 76 of these cases in detail, and while recording many deaths, nonetheless saw this record as verifying the efficacy of undernutrition, reliably citing calorie restriction as the reason for successful cases, and lapses from diet as the reason for failures.
Fasting and undernourishment did free the urine of sugar and apparently reduced the incidence of coma-and-death in children. But child diabetics soon died from infections and other causes, now including inanition. It is uncertain whether calorie restriction extended life beyond the weeks or months gained from avoiding a particular coma event. My reanalysis of the Rockefeller series, showing very high mortality among children, provides little reason to think that it did. This judgment is obviously limited by the absence of a proper comparison
